S811 Metabolic and Bariatric Surgery vs Glucagon-Like Peptide-1 Receptor Agonist Therapy: A Head-to-Head Comparison of Cardiometabolic Risk Profiles

Introduction: Metabolic and bariatric surgery (MBS) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are established treatments for weight loss and cardiometabolic risk reduction. While both have demonstrated efficacy in clinical trials, few real-world studies have directly compared their impact on atherosclerotic cardiovascular disease (ASCVD) risk. This study compares changes in ASCVD risk, lipids, blood pressure, and body weight following MBS (sleeve gastrectomy [SG], Roux-en-Y gastric bypass [RYGB], and biliopancreatic diversion with duodenal switch [BPD-DS]) versus GLP-1 RA therapy (semaglutide or tirzepatide) over 1 year. Methods: This retrospective cohort study included patients treated with MBS or GLP-1 RAs for ≥1 year. ASCVD 10-year and lifetime risk scores were calculated using pooled cohort equations at baseline and follow-up. Between-group comparisons used t-tests and chi-squared tests, and multivariate linear regression adjusted for age, sex, race, body mass index, baseline ASCVD risk, and weight loss. Results: A total of 1,891 patients were included in the analysis (MBS n = 1,088; GLP-1RA n = 803). MBS resulted in significantly greater reductions in lifetime ASCVD risk compared to GLP-1RA (−8.4 ± 12.0% vs −1.7 ± 9.3%, P < 0.0001). Changes in 10-year ASCVD risk were not significantly different between groups (−0.72 ± 2.6% vs −0.92 ± 5.8%, P = 0.62). MBS led to markedly greater total body weight loss at 1 year (−28.5 ± 10.0%) versus GLP-1RA (−11.2 ± 9.3%, P < 0.0001). Improvements in total cholesterol favored MBS (−22.6 vs −8.1 mg/dL, P < 0.0001). Low-density lipoprotein cholesterol declined more in the MBS group (−19.5 vs −6.4 mg/dL, P < 0.0001), while high-density lipoprotein increased by +7.0 mg/dL with MBS versus +2.0 mg/dL with GLP-1 RA (P < 0.0001). Systolic blood pressure decreased by −7.1 mmHg with MBS and −5.0 mmHg with GLP-1 RA (P = 0.0058), while diastolic blood pressure dropped by −4.1 mmHg with MBS compared to −2.5 mmHg with GLP-1 RA (P = 0.0029). In a multivariate linear regression, MBS remained independently associated with greater lifetime ASCVD risk reduction. Conclusion: In a large real-world cohort, MBS led to significantly greater improvements in weight, lipid profiles, and lifetime ASCVD risk compared to GLP-1 RA therapy. These findings provide real-world evidence to inform clinical decision-making in obesity and cardiovascular risk management.